Thursday, February 27, 2020

4096. Anaesthesia in the rabbit

Rabbit Anesthesia and Surgery: Taking the Fear Out

Date Published: 03/06/2001

How many of you have had an experience where either general or local anesthesia was used in order to allow a painful procedure to be performed? Would you have preferred to go without the anesthesia? I seriously doubt it! Anesthesia is one of the greatest innovations in recent medical history allowing the discipline of surgery to be born as well as being useful in a variety of other situations. However, many people are uncomfortable with the “loss of control” that general anesthesia represents. The brain is “asleep” and there is the fear that it will not “wake up” again leaving the patient damaged or deceased. In addition, many people are afraid of surgical procedures because they fear that mistakes will be made during the surgery leading to further problems, or again, death. Fortunately, in this day and age, with improved and safe anesthetic agents, specialized anesthetic and surgical equipment and the ever-expanding knowledge of the medical/veterinary profession, the chances of serious problems with anesthesia or surgery have been greatly reduced.
As with any part of your pet's (or your own) care, the better educated you are about a subject, the more effectively you will be able to make an informed decision. Anesthesia is the subject that is probably the most frightening to rabbit owners because of misinformation, myths and possibly some previous unpleasant experiences. If anesthesia is not allowed, then obviously all surgical and some diagnostic procedures become impossible. In the presentation today, we hope to arm you with not only good information to increase your understanding of what is happening when your pet undergoes anesthesia/surgery, but also give you guidelines to use when communicating with your veterinarian on these important subjects. Remember that ONLY YOU can take charge of your pet's health, no one else is going to do it for you. You must be willing to ask the questions, feel comfortable with your decisions and not wait for others to anticipate any difficulties you are having.
Myths About Rabbits
Rabbits are Fragile
While it is true that rabbits have unique requirements that may be different than those of a dog or cat, they are not “fragile”. We have found over the last 25 years of practice that rabbits can undergo most medical procedures as successfully as any other mammal patients. This myth is primarily based on the fact that in the past owners often didn't recognize that their pet was ill until it was critical. By the time the veterinarian was involved, it was often too late to reverse the process. In addition, the methods and medications used in rabbits in the past were not always appropriate due to our lack of knowledge of pet rabbit requirements. The successful treatment and survival rate of our rabbit patients has more than tripled over the last 15 years due to better informed owners who recognize disease more quickly and improved and more appropriate treatment options.
Rabbits are “High Risk” Anesthetic/Surgical Patients
We do not feel that rabbits are at higher risk with anesthesia or surgery than other patients that we see are. The one exception is that rabbits are more sensitive to surgery involving the gastrointestinal tract that will be discussed in the surgery section of this paper. The “high risk” myth originated in the past from situations where veterinarians did not properly evaluate, prepare or monitor their rabbit patients during anesthetic and surgical procedures. In addition, the anesthetic agents available for rabbits in the past were not as safe as what we have now. Properly evaluated and monitored rabbit patients make excellent anesthetic and surgical candidates.
Effects of Extreme or Prolonged Stress on Rabbits
The main purpose of anesthesia is to reduce or relieve pain. Pain can represent a powerful stress factor in a rabbit's life. It is therefore helpful to understand what happens to a rabbit when it undergoes extreme or prolonged stress in order to appreciate the positive qualities that anesthesia can have. Studies in rabbits indicate that several things can happen under extreme or prolonged stress including; a drop in body temperature, a drop in blood pressure, damage to the kidneys, loss of appetite, stomach ulcers, cardiomyopathy (heart muscle disease) and ultimately death. Anesthesia can alleviate these problems by relieving pain, which is a stressor.
DEFINITION: Anesthesia is achieved when there is a loss of sensation to either a part or all of the body. General anesthesia renders the patient completely unconscious. Sedation is similar to general anesthesia but the patient remains semi-conscious.
Anesthesia and sedation are used in a variety of situations in veterinary practice including diagnostic sample collection (X-rays, blood work, urine, biopsies), examination (calming difficult to handle or painful animals, thorough examination of the oral cavity), and surgical procedures.
  • Local or topical anesthesia is applied on top of or injected into the skin to remove the sensation from a small area. The anesthesia does not extend more than the thickness of the skin nor wider than the area that the anesthetic is applied. The rabbit remains fully conscious. Local anesthesia might be used for minor skin surgeries or biopsies, placement of intravenous (IV) or intraosseous (IO) catheters, or for ophthalmic procedures. We commonly use a topical anesthetic in the eyes to allow flushing of the tear duct in the conscious pet.
  • Regional anesthesia is where a larger and deeper area of the body is anesthetized. The anesthetic agent is injected into the spinal fluid, which numbs all sensation from that point of the spine to the back of the animal. The agent can also be injected into a specific nerve, which anesthetizes all the tissues that the nerve reaches. During regional anesthesia the rabbit remains fully conscious. This type of anesthesia has been successfully used in the rabbit, however many veterinarians are still unfamiliar with the technique.
  • General anesthesia circulates through the bloodstream to all areas of the body, including the brain, and causes a complete loss of consciousness. There are basically two ways to administer general anesthetic agents, by injection or inhalation.
    • Injectable anesthetics can be given IV intramuscular (IM), intraperitoneal (IP) or subcutaneously (SC). Injectable anesthetic agents are often used for short surgical procedures, (particularly those in the mouth), or used as a preanesthetic to an inhalant agent. Preanesthetic drugs are used to calm the patient to allow handling for the administration of the inhalation agent or to allow passage of an endotracheal (ET) tube. The biggest drawback to injectable anesthetics is that there is no control over the dose once it has been injected (except in the case of reversible drugs). There is tremendous variation in dosages amongst different rabbits. Injectable anesthetics are not suitable as the only anesthetic agent for prolonged surgical procedures. The recovery period varies with the agent used. In addition, some of the injectable anesthetics are not appropriate in the presence of certain disorders, such as cardiac or kidney disease. Currently, the most commonly used injectable anesthetic agents in rabbits include any of the following (some are used in combination to improve their anesthetic properties); ketamine, diazepam (Valium), butorphanol, propofol, medetomidine and opiods.
    • Inhalant (gas) anesthesia is the first choice for any major surgical procedure. As mentioned, it is common to use a sedative or preanesthetic agent of some type to relax the rabbit before using an inhalant anesthesia. The anesthetic gas is administered either through a mask placed over the rabbit's face, or through an ET tube. With inhalant anesthesia the patient is connected directly to a machine that delivers the anesthetic agent in a flow of oxygen. The advantages of gas anesthesia are that the concentration of the anesthetic agent and therefore the level of anesthesia can be quickly adjusted, the patient is always connected directly to an oxygen source and recovery is usually rapid and smooth. In addition, isoflurane, the most commonly used gas anesthetic, can be used safely in rabbits with a wide variety of illnesses. Isoflurane is safe not only for the rabbit, but for the humans who are exposed to it in the surgical suite. Methoxyflurane and halothane have been used in rabbits in the past, however, they hold a higher risk of causing medical problems in humans exposed. In addition, methoxyflurane is dangerous to use on overweight rabbits.
With careful preparation and monitoring, the risks of general anesthesia in the rabbit are minimal. However, we would not be truthful if we told you there were no risks at all. Medicine is not an exact science because we are dealing with complex individuals and it is impossible to know every conceivable outcome to every situation.
The complications of general anesthesia range from temporary or intermittent changes in respiration, heart rate and blood pressure to brain damage to death. In experienced hands, anesthetic deaths are rare. The most common causes of anesthetic death include respiratory or cardiac arrest, hypothermia (low body temperature), hypovolemia (low blood volume) and embolism (blood clot). Respiratory or cardiac arrest can be caused by a variety of factors including pre-existing disease of the thorax, (including the heart or lungs), other systemic disease (particularly involving the liver and/or kidneys where anesthetics must be cleared from the body), blockage of the air passageway (blocked ET tube, regurgitation of material from stomach, blood) and overdose of the anesthetic agent(s).
Some degree of hypothermia occurs naturally during general anesthesia because the metabolic rate drops and the body cools. In addition if large areas of the internal surface of the body are exposed, more heat is lost. Anyone who has ever had general anesthesia will probably remember waking up shaking and feeling very cold. Rabbits have a small body mass compared to the surface area of the skin which allows heat to be released even more quickly than in humans. A rabbit's body temperature can drop very quickly to dangerous levels particularly if the abdominal cavity is opened or the procedure is lengthy. Hypovolemia occurs if the patient loses a critical amount of blood or other body fluids during a surgical procedure or a state of dehydration presurgically is not corrected. An embolism (blood clot), although fortunately rare, can occur anytime, particularly if the surgery involves manipulation of a large blood vessel, bone tissue or if the rabbit had a serious bacterial or fungal infection prior to the procedure.
Fortunately there are many things that can be done to greatly reduce the anesthetic risk in rabbits. Factors that increase anesthetic risk include; no presurgical physical exam, pre-existing disease (particularly respiratory, heart, liver or kidney disease, dehydration or obesity), inappropriate anesthetic agent or dose, absence of regular anesthetic monitoring, and absence of adequate postanesthetic monitoring and care.
Here are some things that the veterinary staff can do to minimize anesthetic/surgical risk:
  • Perform thorough preanesthetic/surgical examination including diagnostics if appropriate.
  • Stabilize/treat pre-existing conditions
  • Use anesthetic agents/dosages appropriate for rabbits. Obtain accurate body weight.
  • Continuously monitor the patient during the anesthetic/surgical procedure.
  • Closely monitor the patient during the recovery period until awake and moving.
Now let us now go through the process of taking your rabbit in for a surgical procedure from beginning to end so you can understand what to expect.
Every rabbit that is going to undergo an anesthetic or surgical procedure should have a thorough physical examination performed. There is no exception to this rule! You would not expect your doctor to put you under anesthesia unless you had been thoroughly examined and you should not expect less for your pet. Depending on the type of procedure being suggested and the age and condition of the rabbit, your veterinarian may also suggest certain diagnostic tests. The most common tests include any of the following; a complete blood cell (CBC) count, serum biochemistries, X-rays, ultrasound, ECG and/or urinalysis. Your veterinarian can explain the reason for the tests in each case.
*Important: In situations where owners decline recommended preanesthetic/surgical diagnostics, the risk factor for the rabbit may increase because the veterinarian cannot acquire all the needed information to make an informed decision on the suitability of the patient to undergo anesthesia/surgery.
It is important to stabilize or treat any disorder present at the time of the physical examination, such as dehydration, infections, liver or kidney disorders, heart or lung disease or breathing difficulties prior to the administration of the anesthetic. The most common condition that we see that interferes with anesthesia and surgery is obesity. Overweight rabbits are always considered high-risk patients due to the possibility of concurrent liver disease (fatty liver) and respiratory problems due to the pressure of excess fat on or in the chest cavity. Unless there is a life-threatening situation that requires immediate surgery, overweight rabbits should complete a weight reduction program prior to anesthesia.
*Important: It should be noted that there are rare situations where a preexisting health condition that interferes with safe anesthesia/surgery is not detected in a rabbit. As mentioned previously, we are dealing with complex creatures and all our tests are not infallible. However the occurrence of such situations when a thorough preanesthetic evaluation is done are extremely uncommon.
Anesthetic induction is the administration of the anesthetic agent(s). Due to the nature of the rabbit gastrointestinal (GI) tract and the fact that they cannot vomit, it is not necessary to fast a rabbit prior to induction. Some veterinarians prefer to remove the food one to two hours presurgically to make sure the rabbit's mouth is clear of food. As previously discussed, your rabbit may be given preanesthetic drugs, including pain medications, prior to receiving general anesthesia. The general anesthetic is administered either by injection or by inhalation. Induction with gas anesthesia can be accomplished via an anesthetic chamber, a face mask or an ET tube. The rabbit is maintained under general inhalation anesthesia with either a face mask or ET tube.
Once your rabbit is unconscious, he or she is placed on a warm pad to help prevent heat loss. In some cases an overhead source of heat is also be used. The mouth is cleaned of any food or excessive saliva. At this time if an ET tube is going to be used, it is put in place. If an IV catheter was not placed prior to surgery, it will be placed now that your pet is unconscious. Except for short procedures in healthy animals, it is advisable to have an IV catheter in place in case emergency drugs need to be given quickly and to be able to administer fluids. Most rabbits undergoing lengthy surgical procedures will receive IV fluids to prevent dehydration and replace blood loss. It is preferable that the fluids be warmed to help maintain normal body temperature. At this time monitoring devices will be attached.
There are several parameters that are monitored during an anesthetic/surgical procedure and a variety of monitoring devices can be used.
  • Respiration - Respiration can be monitored visually by an assistant, through a regular or esophageal stethoscope, by a respiratory monitor (attaches between the ET tube and the anesthetic machine to measure changes in airflow), or by a pulse oximeter (measures oxygen saturation of the blood).
  • Heart Rate/Pulse - The heart rate or pulse can be monitored by a regular or esophageal stethoscope, an ECG machine, a Doppler or a pulse oximeter.
  • Body Temperature - The body temperature is monitored with a rectal thermometer.
  • Reflexes - Monitoring the rabbit's response to certain stimuli helps to assess the depth of anesthesia. There are several ways of doing this, but the most commonly used tests are pinching the toe and touching the eye. If the toe is pinched and the rabbit tries to pull its foot away or if the eye is touched and the rabbit tries to blink the anesthesia is too light. The rabbit may appear to be unconscious, but positive reactions to these tests indicate that it can still feel pain, so the anesthetic will be adjusted accordingly.
Once the procedure is completed your rabbit will enter the recovery period. Inhalant anesthesia will be discontinued and oxygen will be administered for a few minutes prior to disconnecting the anesthetic machine. The ET tube will be removed as your rabbit starts to show signs of awakening. Reflexes will be checked with increasingly strong responses indicating recovery from anesthesia. Your rabbit will be moved to a recovery area. It is preferable that this area be quiet but visible to the veterinary staff who is monitoring the recovery. The amount of warmth your rabbit will need during recovery will depend on the body temperature at the end of the procedure. Most rabbits need only a brief period of extra warmth until recovery. Respiration and heart rate will continue to be monitored, usually by direct observation and stethoscope, until your rabbit is fully awake.
Although this is primarily a discussion on anesthesia and surgery, we cannot leave out the important aspect of pain control in the rabbit after a painful procedure is performed. As mentioned, moderate to severe pain can represent a serious stress to the rabbit and can result in some potentially dangerous consequences. Many years past when we did not understand the full significance of pain management in rabbits, they would often survive a surgical procedure, only to die within the next 36 hours. The old cliché of 'the operation was a success, but the patient died” would apply to those situations. Some of these cases would most likely have survived if postsurgical pain had been managed thereby reducing the stress on the rabbit. You know that if you have had a painful procedure performed that you would prefer pain-alleviating medications to being uncomfortable. Rabbits in pain recover more slowly. Analgesics may not always be needed for minor procedures, but should consistently be used for all major surgeries.
The most common analgesics currently used in rabbits include butorphanol, buprenorphine and nonsteroidal anti-inflammatory drugs ( NSAIDs) such as aspirin, carprofen, diclofenac, flunixin, ibuprofen, indomethacin, ketoprofen, meloxicam, acetominophen and piroxicam. An alternative source of analgesia for chronic mild to moderate chronic pain relief is acupuncture or acupressure.
Your veterinarian should advise you on the specific signs to be aware of in your rabbit after an anesthetic/surgical procedure. Here are some general behaviors that might be observed:
  • Quiet Behavior - Your rabbit may want to sleep and stay quietly in one area. The lack of activity can be caused by residual anesthetic in the body, pain, or medication. Some analgesics have sedative properties and may add to the lethargy. Check with your veterinarian about what you should expect with any drugs you are giving to your rabbit. If your pet is extremely lethargic, is crying out or appears unable to move normally and sits hunched in one spot, you should contact your veterinarian immediately.
  • Poor Appetite - Your rabbit may not eat or drink at all for the first 24 hours after returning home. Analgesics may improve this situation but not completely eliminate it. You can syringe feed your pet thin slurry blenderized fresh vegetables mixed with fruit juice or canned pumpkin (not pumpkin pie filling) one to two times during this initial 24-hour period. If your rabbit still refuses to eat after 24 hours, you should contact your veterinarian immediately.
  • Abnormal or Absence of Stools - Anesthetic and analgesic agents can alter the motility of the GI tract. In addition, the rabbit may have eaten poorly just prior to surgery, therefore, there may be an absence of stools for a period up to three days after anesthesia/surgery. If stools are present, they may initially be smaller than normal, misshapen or soft. This condition should clear up within three days. Watery, diarrhea should not be present and is cause for immediate concern. Please contact your veterinarian should you have any questions about your rabbit's stools or urine.
To summarize what you have learned, here are questions that you can ask your veterinarian that cover the areas of concern regarding anesthetic/surgical procedures.
  • Experience Level - Ask about the experience level of the veterinarian regarding rabbits in general and about the procedure in question. Your veterinarians may not have had a lot of experience, but based on the answers to the other questions here and the willingness to work with you, you may decide to go ahead with the procedure.
  • Types of Anesthetic Agents Used - You now have a list of anesthetic agents that are commonly used. If your veterinarian is using something else, ask for some type of literature or their experience in using these drugs before making your decision.
  • Explain the anesthetic/surgical procedure – You are entitled to know how your pet is going to be handled throughout the anesthetic/surgical process. You now have a detailed description of the kinds of things that should be happening to decrease risk. In particular, find out about preanesthetic evaluation, anesthetic monitoring, recovery monitoring and use of analgesic agents.
  • OVARIOHYSTERECTOMY (SPAY) - This is the complete removal of the uterus and ovaries in the female rabbit. Spays are done to prevent pregnancy and uterine cancer and to help control some behaviors such as urine marking, aggression and false pregnancy. The surgery should be performed after four months of age and before two years of age. The risk of uterine cancer increases significantly after two years of age.
  • CASTRATION - This is the complete removal of the testicles of the male rabbit. There are several surgical approaches possible. Castration is performed for birth control and behavior modification such as urine marking and aggression. It will also prevent testicular cancer, although reproductive cancer is more rare in male rabbits than in female rabbits.
  • DENTISTRY - Dental disease is common in rabbits due to such things as inappropriate diet, genetics and trauma. Because rabbit teeth grow continuously, dental malocclusions require continual reshaping of the teeth throughout the pets' life. In some situations the teeth need to be completely removed. Difficulties in rabbit dentistry include the small size of the oral cavity, which limits visibility, and work area, and the long extensive roots of the teeth. It is best to have dental procedures such as trimming or extractions performed as early as possible in the disease to avoid further complications.
  • ABSCESS REMOVAL - Abscesses can occur in or on any part of the body, but have a particular propensity for the head. Most of the facial abscesses are related to dental disease. If at all possible, abscesses should be completely removed. There are often draining tracts that go between tissue planes and if left behind they can become sources for future abscesses.
  • GASTROINTESTINAL SURGERY - GI surgery is most often done to remove blockages in the GI tract. These can occur anywhere along the tract and can be caused by dried pieces of stomach contents, carpet fibers and rubber or plastic objects. GI surgery holds the highest risk of complication in rabbits because of two factors:
    1. The rabbit is often already in a deep state of shock once the obstruction is discovered placing it at high risk for anesthesia or surgery and 2. Because the GI tract is very sensitive to surgical manipulation.
    The GI tract (particularly the cecum) may not heal well after surgery and the surgical site can break down. Abdominal adhesions are more common after GI tract surgery. In addition, GI motility can be affected causing a GI shutdown. These patients need an extraordinary amount of medical care and monitoring. The first three days after surgery are the most critical and the rabbit should be hospitalized during this period.
  • OTHER SURGERIES - Surgery can be performed in the rabbit on any system or organ, just as in other animals. A list of other commonly performed surgeries includes cystotomy (opening the bladder usually for tumor or stone removal), orthopedic, laceration repair and tumor removal. Your veterinarian can give you details on these surgeries should your pet require them.

4095. REYNA. A rabbit has a painful eye ulcer. Chronic ulcerative keratitis


20 Feb 2020. The rabbit has a painful eye ulcer. Pt 1/2. Chronic ulcerative keratitis Treatment by antibiotic eyedrops for several days at Toa Payoh Vets in December 2019. The ulcer had 'disappeared' . The owner got the rabbit home but the rabbit was furious with the Elizabeth collar and pulled it out. The owner did not make the rabbit wear the Elizabeth collar. The eye ulceration returned. The rabbit has lost weight and needs to be warded for a few days for treatment and to recuperate to regain weight. The owner opted for eyeball removal as this would stop the daily eye pain, but the rabbit had to gain weight to be fit for anaesthesia and surgery. In this consultation, the ulcer is deep and the cornea is very cloudy. The rabbit is quite old and healing may not be possible if eye surgery is performed. An option will be to remove the eyeball (enucleation) so that the rabbit does not suffer from any more eye pain and loss of appetite. There is anaesthetic risk as the rabbit is 9 years old, towards the end of life. The owner will wait another 7 days of inpatient treatment to think about it.

Dec 2019 images

20 Feb 2020 images

27 Feb 2020 images

The rabbit's routine is freedom to roam in the apartment. Dust and air irritate the ulcerated right eye, leading to more rubbing. The cornea became infected and inflamed. A cloudy cornea with a central ulcer existed.  It can be painful, leading to more rubbing to relieve the itchiness.  Eyeball removal is the treatment of choice. The owner is worried about anaesthetic risks. Wanted to wait another week. 

1. Early detection
2. Early treatment within 24 hours of injury is best
3. Diagnosis - Fluorescein eye stain test
4. E-collar
5. Review

Save eye

4094. A hamster 'loses weight',

Thursday Feb 27, 2020

Existing client. Japanese or Korean lady. The hamster came in 5 months ago as he was limping. Now he has recovered. The owner texted a WhatsApp appointment to Toa Payoh Vets at 96686468.

"Hi, I would like to bring my hamster (for a health check). He is almost 1 year old and is getting skinny. What time and day can I come with  my hamster?" 

"Our hamster is losing weight" the husband had informed the wife. "A hamster had died suddenly after showing signs of breathing difficulties."
"Is he eating and drinking normally?" I asked.
"No problem".
"Are his stools normal is size and in amounts?"
"She weighs 50g," I showed her the weight on the scale. "In the Sep 2019 consultation for limping, she weighed 49g as recorded in the medical files.  Your hamster is very active and is in good bodily condition. Her weight is average although 55 g will be better."

 The owner had another hamster at home. This one would be overweight at over 60g.  I checked the housing. It was a crate with grilles on the top 2/3 of the crate. 

"The hamster loves to climb the bars or grilles," I told the owner. "This is not good as many hamsters do fall down and injure themselves.
"Yes,"  the lady nodded. "He also gnaws at the grilles!"
"He was limping some 5 months ago," I referred to the records. "He could have fallen from the grille and injured his leg. Fortunately he did not fracture his leg and has had recovered!"

I asked my assistant to help me open the hamster's mouth to check the teeth. "There is no overgrown front teeth," I showed the owner. "So he has no dental problems in chewing and biting food."

A strong bad breath smile wafted up from the hamster's mouth. The cheek pouches were filled with seeds and meal worm pieces as my assistant used a pair of forceps to widen the mouth. The lady covered her nose.
Hamsters do not have bad breath normally.

"Where did you get the meal worms?" I asked the lady who feeds 2 meal worms a day. "I bought them from the Pet shop,"

4093. A red-eared slider has difficulty laying eggs - ovocentesis


No response to oxytocin injections

 Oxytocin injection successful

Cannot lay 15 eggs

Tuesday, February 25, 2020

4092. Syringe feeding a red-eared slider - videos


*Final Video. This video shows the process of syringe feeding the slider.


4091. An emaciated dog was not eating and standing up. Why?

In Singapore, many dogs live to a ripe old age of over 10 years. However, some become very thin or emaciated. There is a belief by some owners that weight loss is a natural progression of ageing. The
dog "does eat" but cannot put on weight. 

"My dog is unable to stand up and has head tremors," said the lady owner. "I had brought him to see you some 8 years ago."

"Your dog is emaciated," I pointed to the visible ribs of this cross-bred dog. "There is no body fat. she has lost most of her teeth and has pale gums, suggesting anaemia. This means insufficient fed blood cells and haemoglobin."
"I feed her the most expensive food purchased from the Pet Shop," she informed me. "My dog does eat it."
"If he ate the food, he ought to put on more weight. I will need a blood test to check the health of his blood system, liver and kidneys."

The owner gave consent. Blood test showed very low red blood cell numbers and disorder of the liver and kidneys. Together with the signs and symptoms, the dog is in very poor health. An IV drip perked her up as she felt stronger. A therapeutic diet of Hill's K/D was prescribed. However, the dog's health deteriorated and he passed away at home 5 days later.  

Old dogs do not lose weight if they are healthy. Consult your veterinarian for early detection of disease and treatment.




Ataxia, head tremors

Ribs are prominent

Pale gums. Most teeth had dropped out

TP 42087

Abnormal results:
ALT 878 U/L  (normal is less than 59)
AST 171 U/L  (normal is less than 81)

Urea 67.4 mmol/L  (normal is 4.3 - 6.3)
Creatinine 329 umol/L (normal is 89 - 177)

Haemoglobin 8.6g/dL  (normal is 12 - 18)
Red cell count 3.6x10^12/L (normal is 5.5 - 8.5)
Haematocrit (PCV) is 0.27 (normal is 0.37 - 0.55)

Monday, February 24, 2020

4090. REYNA. A rabbit has a watery eye. Epiphora.

A rabbit has a watery eye. Epiphora.

Tears overflow right eye downwards to the nose
What are the causes?
1. Usually two main causes - the corneal or obstruction of the
lacrimal drainage 

Eye irrigation of the right eye, to flush away foreign bodies like grass seeds and dirt under general anaesthesia.
In-patient for 4 days. Went home. 

"Doc, look at the eye! No green corneal ulcer, right?" my assistant said as she saw no green stain on the cornea.

The owner said the rabbit had recovered from the eye ulcer.
He had passed away as he was aged at 8 years.


A proverb. There's always some reason for a rumour or signs of a problem.

Saturday, February 22, 2020

4089. REYNA. A dwarf hamster has two large mammary lumps

Thu 21 Feb 2020

The young lady came to Toa Payoh Vets as her first hamster passed away during surgery to remove a shoulder tumour at another vet clinic. The hamster died on the operating table. So the lady surfed the internet and made an appointment with Toa Payoh Vets today.

"There is always a risk in anaesthesia," I explained to the owner. "No vet can guarantee 100% risk-free anaesthesia and surgery."

"My hamster bites," the young lady warned me. "She has one large globular lump."
On closer examination and under restraint, I discovered she had two. They measured around 8m x 8 mm. That meant a longer time to anaesthesize, increasing the risk of death on the operating table.
We let the hamster rest for one day and gave pre-op antibiotics and painkillers.

The owner decided to take a chance on a different vet clinic. The hamster was operated by Dr Daniel Sing the next day and would go home today, Saturday. All was OK (show video post op).

Anaesthesia - describe
Surgery - describe
Histology of tumours done?

  A cyst with small tumours?
A tumour? 


FOLLOW UP PHONE CALL ON FEB 27, 2020 - Hamster is OK. 

Thursday, February 20, 2020

4088. Story telling using the 3Ds - Do dogs suffer from toothaches? Carnassial Tooth Abscess in a Pomeranian

The 3-act structure prevents boredom. Arranging events in an order that conflict causes change, which in turn causes more conflict, building and building, until the story's final confrontation and resolution. 3 acts. Beginning, middle and end. 

From a plot point of view: Set-up, Conflict, Resolution
From an emotional POV, Attraction, Tension, Satisfaction
From a thematic POV. Subject, Development, Fulfillment.

Grab the reader's attention by establishing the genre and mood, which create the anticipation of desired feelings such as laughter for a comedy or tension in a thriller. 

First, introduce the main character with whom the reader will bond. You estabish the main problem which captures the reader's interest and creates curiosity and anticipation as to how the protagonist will solve his dilemma. The opening hook is an essential emotional element in this act.

Several types of opening:
1. Hero in action.  Introduce the protagonist in the middle of conflict (most common opening, most effective---character bonding and drama). This hero in action opening gives you a choice to focus on e.g. character's uniqueness or character empathy (misfortune or mistreatment). 

2. Villain in action. 
3. Backstory/prologue  eg. traumatic prologues
4. Spectacle e.g stunts, special effects, over-the-top events generate thrill for the reader. Joyous occasions like a wedding (The Godfather).
5. Mystery. Intriguing event that arouses curiosity in the reader, making him wonder what is going on, is also a great way to open a script. Alien, The matrix,E.T. --- where are we? Who are these characters, what are they talking about, what's going on?

6.  Unique world. World of the mafia (The Godfater), world of aliens on earth (Men in Black), the Amish world, panoramic bird's-eye view of a future Los Angeles - Blade runner. 

7. Exposition. As long as the basic information about the world of your story is intereswting and crucial to the understanding of the plot e.g. the scrolling exposition (Star Wars). 

8. Breaking the fourth wall. A rare but effective way to open a story with a character speaking directly to the reader which creates immediacy and connections. e.g. voice-over eg. American Beauty or Sunset Boulevard or having the character speak directly into the camera, thus "breaking the fourth wall", e.g. High Fidelity, Ferris Bueller's Day off or Annie Hall.  

9. Book-ended flashback  A popular device or structure to open period pieces or detective stories that involves investigation of a past event.  Eg. Titanic, Amadeus, Citizen Kane, The Bridges of madison County or Double Indemnity. Make sure the past is more important than the one in the present. 

10. STORY TELLING USING THE 3D's to sell a product or service
All wrapped up in Drama


In this case, this rabbit has been diagnosed with malocclusion, which means misaligned teeth. As we can see in this video, the 4 upper jaw teeth (2 maxillary incisors and 2 peg teeth) were overgrown and grew sideways. The 2 lower jaw teeth (2 mandibular incisors) were overgrown and broke off. Therefore, it appeared very small.

What is Malocclusion?

Malocclusion means misaligned teeth and a rabbit with misaligned teeth cannot eat hay and other food easily.

How it is developed?

A rabbit’s teeth are constantly growing and it is crucial that the normal process of chewing wears down a rabbit’s teeth. When the teeth are not worn down, they overgrow. The top incisors grow inwards towards the mouth and the bottom ones grow outwards. This can lead to the rabbit at risk for jaw infections causing pain and discomfort.

Why is it important?

If left undetected, your pet will eventually stop eating. Rabbits need a continual supply of roughage moving through their digestive system to prevent gut stasis. Even 12 hours without food can cause serious digestive disorders and further health complications like death. The rabbit dies if he is not treated as he becomes malnourished and dehydrated over time.

How it is diagnosed?

Malocclusion is diagnosed by the physical examination of the rabbit’s mouth and X-Ray of the jaw and tooth root. The treatment will depend on the severity of the malocclusion.

Reasons for Malocclusion?

Rabbit malocclusions can be either hereditary or acquired. Hereditary malocclusion are observed more in dwarf breeds due to their shortened heads and jaw developments. However, majority of malocclusion are acquired when the teeth are not ground down properly over time and are often due to poor feeding practices. It’s recommended the majority of a rabbit’s diet comprises hay (80%), with a limit to vegetables (10%), fruits (5%) and pellets (5%).


Preventions for Malocclusion?

Malocclusion can be easily prevented by the correct diet advised by veterinarians. Hay is a crucial ingredient in a rabbit’s diet as it helps trim the constantly growing rabbits teeth. Routine health check every once to twice a year ensures that the rabbit’s teeth are not overgrown. When abnormal growing of the teeth is observed during vet visits, the teeth are trimmed before it gets overgrown.

Treatment for malocclusion?

The overgrown teeth are being trimmed by the veterinarians.

In severe cases, surgery to remove the affected teeth may be an option. Any tooth with deep pockets, mobility and purulent debris is subject to extraction, especially if an abscess is present. Extraction of the overgrown front teeth will have prevented the development of molar spurs and dental abscess which are expensive treatments.

In this case, the extraction of the 6 front teeth enables the rabbit to eat properly. Rabbits without their incisors use their lips and tongue to pick up food and move it to the back of their mouth, where it's ground by the molars. However,

Rabbits cannot live without any teeth. Therefore, it is important to detect malocclusion earlier or even better to prevent it. Is it crucial to remove the teeth or trimming is sufficient and a better choice?

Other dental problems (Is it needed to include molar spurs?)

Molar spurs are sharp edges developed by the overgrown molars. They are present when the incisors are overgrown and causes difficulty in chewing the food properly. The inability to grind the food properly leads to the sides of the molars to get worn out abnormally.

The developed sharp edges cut into the inside of the cheeks causing cheek ulcerations and entrapment of the tongue, making it difficult for the rabbit to move its tongue to eat properly. Molar spurs causes incorrect positioning of the molars, leading to bacteria entering the roots of the molars causing dental or jaw abscess.

Complications of dental problems are very painful and expensive treatment. Therefore, it is very important to bring your rabbits for regular dental exams every once to twice a year. Prevention is always better than cure.

STORY TELLING USING THE 3D's to sell a product or service
All wrapped up in Drama



The Carnassial Tooth Abscess
Dr Sing Kong Yuen, BVMS (Glasgow)

Dogs do suffer from toothaches. I will say that the most painful one must be the carnassial tooth
abscess. The canine carnassial tooth is the 4th premolar tooth. When there is chronic gingivitis or tooth fractures, the bacteria destroys the periodontal ligaments attaching the tooth to the gums. Bacteria destroys the tooth and forms a carnassial tooth abscess. An abscess is a collection of pus.

Carnassial tooth abscess is a common disease in the older dog that has poor dental care. It is very painful. The presenting sign is a festering facial wound below the eye. Pus and blood seep out daily like an active volcano spewing hot lava and ash daily. Home remedies like antibiotic powder and silver cream or antibiotics are ineffective. Most owners think this is just a traumatic wound. But this open facial wound never heals, despite medication and cleansing as shown in this case of a 4-year-old Pomeranian seen at Toa Payoh Vets in 2007. 

“I am sick and tired of cleaning this wound for the past many weeks,” Mrs Jaswant Singh pointed to the wound below the Pomeranian’s left eye. “I pour antibiotic powder and also gave antibiotics, but the wound keeps discharging dirty blood daily! My cat could have scratched my naughty baby causing this wound or something sharp had poked into his face!”

“This wound is a result of a tooth root infection,” I took out the Hills’ illustrated drawings of this common dental disease in dogs in Western countries. It is easier to show than to tell. I lifted the dog’s left upper cheek, but the carnassial tooth showed thick tartar and an inflamed gum. No pus and blood leaking out from the gums. “The permanent cure is to extract the rotten carnassial tooth. Antibiotics will not resolve the problem.”

“Just get on with the tooth extraction,” Mrs Singh showed me her dog’s discharge stain in her silk black sari with big red flowers. “My saris are very expensive as I buy them from New Delhi in India, not from the shops in Little India here! My baby keeps soiling them. I have to clean the soiled bed, sofas and mop the floor to remove her discharges for the past weeks! I have no maid to help me.”

“Hey, wait, wait, wait,” Mr Singh interjected. “Are you sure our dog suffers from carnal, cunning or whatever?”  As this was their first visit to Toa Payoh Vets, the husband eyed my diagnosis as money-making.

This doctor is talking nonsense,” Mr Singh whispered, not too softly in his wife’s ear. “The tooth and the wound are so far apart and separated by the sinus bones. How can infection travel so far? He must be nuts and out to make money from us!”

“I can take an X-ray to show you that the root or roots of the carnassial tooth is infected,” I said when Mr Singh turned towards me. “No need to do it,” the husband put up his hand. “Thank you very much. We will let you know if we want you to pull out the tooth.”

Around 2 months later, Mrs Singh consented to the dental extraction. There is the root canal and associated treatment, but it will be expensive. I extracted the loose left carnassial tooth and the first molar.

In the blink of an eye, 6 years passed by when Mrs Singh had her Pomeranian treated for bad teeth. “My dog’s facial sore healed within 10 days,” Mrs Singh reminisced. “Hence, I do not see you.” 
She did not get her dog’s teeth checked yearly as advised by me. Her dog had not suffered another carnassial tooth abscess in the right side but now had several loose and decayed teeth extracted.

Carnassial tooth abscess is also known as malar abscess or oro-nasal fistula. Some vets do mis-diagnose this disease as allergies or infected traumatic wounds. A spot-on usually accurate diagnosis is made if there is a festering non-healing facial wound below your dog’s eye. Dental extraction is the least expensive effective treatment. Yearly dental check ups will prevent most of your dog’s teeth from decaying so that your dog has teeth up to old age.

FOR MORE INFORMATION: Phone 6254-3326, 9668-4668,,


General anaesthesia for dental works.  Periodontal Disease.
4th premolar and lst molar teeth are encrusted
with thick tartar. There is inflammation of the gum area - chronic gingivitis 

Image 2. Rotten 4th premolar and lst molar teeth extracted  and are shown
to the owners

Image 3. No more oro-nasal fistula since the
dental extraction 6 years ago